East Africa 3-year Strategy & Impact Update: 2020-2022 Dec 2019 - Enterprise for Development
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East Africa 3-year Strategy & Impact Update: 2020-2022 Dec 2019
Jacaranda Health’s vision is a world where all women and their
families experience childbirth safely and with dignity
OUR APPROACH
We partner with government health
1 systems where 80% of women deliver
Improve quality of care with a package
2 of proven, low-cost interventions
Scale to improve health outcomes in a
3
critical mass of public hospitals
Our innovations adopted as
4 national standard of care
Jacaranda is transforming maternal healthcare with
high-quality, sustainable care in the public and private sector
Jacaranda Health focuses on impacting maternal outcomes in the public health sector where 80% of women deliver.
We replicate innovations in service delivery from our own hospital providing high-quality, affordable care to Kenyan
mothers. The two orgs are managed and financed separately, but work together closely.
Patient
Centered
Care
Non-profit
Adapts and scales key
Social enterprise
innovations in public hospitals: • Highest quality maternity
• Proven impact hospital in East Africa, 1/5th
• Low-cost and sustainable in cost of private hospitals.
public health system • Replicable low-cost model
• 100+ partner hospitals in five • Raising impact investment
counties across Kenya in capital to grow to largest
2019 - growing rapidly with chain maternity hospitals in
government demand. Kenya
HR Innovations
Quality
Systems
The challenge: Poor quality of care is at the root of poor maternal and neonatal mortality in Africa Across Africa, there has been a significant increase in access to maternal healthcare: In Kenya, births in facilities have gone from 40% to over 60% in the last 5 years. 80% of those births are in public hospitals. However, maternal and newborn mortality remains among highest in the world because of the poor quality of care received in hospitals. Jacaranda addresses this challenge.
Almost 90% of facility-based maternal and newborn deaths are
preventable with skilled care at the right time during pregnancy
KEY INGREDIENTS IN THE GAPS LEADING TO POOR
PREGNANCY CONTINUUM OUTCOMES
Mothers seek 33% of maternal
appropriate, high
deaths are caused by
quality care at the
delays in seeking care
right time
Childbirth attended 55% of maternal
by competent, deaths are caused by
skilled healthcare delays in action or
providers
inadequate care by
providers
Our innovations are addressing these critical
gaps in quality of care in public hospitals
KEY INGREDIENTS IN THE GAPS LEADING TO POOR JACARANDA’S SOLUTIONS
PREGNANCY CONTINUUM OUTCOMES ADDRESS CRITICAL GAPS
Mothers seek PROMPTS: a rapidly scaling
33% of maternal digital health platform that
appropriate, high
deaths are caused by connects mothers with
quality care at the
delays in seeking care lifesaving advice and referral to
right time
care
Childbirth attended 55% of maternal NURSE MENTORS: Intensive, on-
by competent, deaths are caused by site nurse mentorship program
skilled healthcare delays in action or Improves and sustains in life-
providers saving emergency obstetric skills
inadequate care by
providers
SOLUTION 1: Empower women to visit health facilities at key
points during and after pregnancy
KEY INGREDIENTS BEHAVIOR GAPS OUR SOLUTION
Mothers seek 42% of pregnant women do PROMPTS: a rapidly scaling
appropriate, high not attend 4 antenatal care digital health platform that
quality care at the visits connects mothers with
right time lifesaving advice and referral to
68% of new mothers have an care
unmet need for postpartum
family planning
Childbirth attended 47% of mothers do not have
by competent, postpartum visits
skilled healthcare
providers
Vision 2022: We will deploy these tools in 200+ public facilities across
10 counties, improving quality of care for over 1M mothers and babies
We partner closely with the county governments By 2022 we will be working in this densely populated
who manage health systems and budgets. Today, region that accounts for 40% of the births in Kenya
our solutions have been deployed in over 150
health facilities across 5 counties
10 counties 200 facilities
250k annual
births with
better
Current coverage outcomes1
Targeted coverage
We will also pilot expansion of our programs 1 Estimated coverage for PROMPTS is 240K annual births by 2021;
to one new country in the next two years Mentors 90-100K annual births by 2021 (250k cumulative, 2019-2021)
PROMPTS is a platform of digital solutions that connects
mothers to lifesaving care
The Challenge
2
1 3
4
PROMPTS is being rapidly scaled across public facilities
• ~100,000 mothers enrolled to date A nation-wide platform: our goal is for every
across 150 facilities pregnant woman and new mother in Kenya to
• 12,000 new mothers added every month have access to PROMPTS, through a national
platform that can reach 750,000 mothers/year
and supports over 1M questions/year.Cost and impact 83% Of moms seek medical care upon
referral
83% of moms PROMPTS flagged
with danger signs followed up to
seek care at the hospital
$0.74 27% Increase in 4th ANC visits
Facilities that are using
PROMPTS are seeing a 27%
per mother increase in number of women
attending 4 ANC
..more likely to take up family
1.8x planning
1.85x more likely to take up PPFP
~2x more likely to take up long
acting contraceptives.How our machine learning supports the helpdesk
AI prioritizes
urgency of question
AI suggests response for helpdesk agent
Bot can understand content and determine intent in Swahili, English or “Sheng”
TriageBot shows 95% accuracy in categorizing intent, urgency, and suggested
responseMothers text in thousands of questions about pregnancy and
Our Public
new babiesSector Strategy
We now receive 500+
questions per day
70% of the questions asked are
general pregnancy, but 30% are
43% of mums ask at least
potentially medically urgent
one question.
We created a helpdesk
service to answer mothers’
questions
• Standardized
responses
• Escalation to clinical
staffAI-supported helpdesk is designed to maintain quality at scale
Our Machine Learning (ML)
“triageBot” help us triage incoming
Time to first response (hrs)
messages, prioritize them for
urgency and provide suggested
responses
Our helpdesk agents now respond
to high priority messages 2x faster
than other messages, and time to
response has been reduced by
over 60% to less than 30 minutes.We are able to assess client experience with quality
of maternity care
1 We send an SMS client experience survey to
cohorts of mothers every month 2 Facility in-charges
receive their
“Were you treated with respect during your last
individual scores
visit?”
I was abused & slapped when I was telling them my
problem during delivery
They were friendly and caring. They explained to me what i
should be eating because my haemoglobin was low and
they also gave me some tablets
Survey 1 Survey 2 Survey 3 Survey 4 Survey 5
3 Facility 1 92% 95% 93% 93% 87%
Dashboards are shared with Sub-
Facility 2 98% 99% 91%
County Health Officials and
Facility 3 96% 89% 94% 95% 100%
Reproductive Health Coordinators
Facility 4 92% 87% 96% 93% 88%
Facility 5 91% 100% 98% 96% 89%
Facility 6 100% 96% 86% 90% 76%
Facility 7 100% 88% 82% 83% 93%Referrals: Using data to connect mothers to care
Case study of Rose, a new mother in Kiambu County
1 week after delivery and she has 1
been bleeding excessively – she
fills a pad before an hour is over.
When her message is seen, she is
2
called by a helpdesk agent. She is
reluctant to go to a health facility
because there is no one to watch
her baby. However, she consents to
share her phone number with the
facility and her location. * Rose’s location
and potential
referral sites
The helpdesk agent uses the 3
referral map to find the contact of a
champion nurse at the facility near
Rose. The champion calls her,
convinces her to go, and prepares
Our helpdesk agent’s referral map
the in-charge to receive her so she
won’t have to wait.SOLUTION 2: Nurse Mentorship empowers providers with skills to
provide consistent high-quality care during childbirth
KEY INGREDIENTS BEHAVIOR GAPS OUR SOLUTION
Childbirth attended Maternal health nurses in Kenya NURSE MENTORS: Our intensive,
by competent, scored under 50% on skills on-site nurse mentorship program
skilled healthcare related to emergency obstetric improves and sustains in life-saving
providers care and newborn care. emergency obstetric skills
APPROACH: Experienced Nurse Mentors work alongside government nurses in public hospitals to build a culture of
quality and sustained improvements in obstetric skills. The approach aligns with government objectives and is
cheaper and more sustainable than existing training options.Our Nurse Mentorship program is improving life-saving care at
public hospitals and creating a sustainable culture of quality
KEY COMPONENTS LEVERAGE FOR SCALE
A training package that
1 Each Jacaranda mentor
includes simulation-based
training
works with 3-4 facilities at a time
2 In-facility coaching that for 4 months (10-12/year)
improves and sustains skills
training and coaching 10-20
frontline nurses per facility
3 Problem-solving advisory
support that resolves
bottlenecks to delivery of
life-saving care. who oversee 1000+ deliveries/ yearNurse Mentorship program: Key components for impact
Mentor Recruitment Monitor progress and
1 2 Rotation in public hospitals 3
& Training gaps in real-time
Rotation
Targets
achieved?
Rotate to
We measure and report on: next batch of
• Improved clinical scores from facilities
Onboarding: 6 weeks
observations
• Partograph completion and
6 weeks training: Minimum 4 months in each facility neonatal resuscitation
• Obstetric skills • Observe & improve • Teamwork and
• Rotation in • Run Continuing Medical Education communication
Jacaranda Maternity • Simulation Drills • Health outcome data at a
• Shadow mentors • Mentorship, identify champions facility levelNurse Mentorship program: Sustained improvements in quality
Mentors observe and score performance of staff during live deliveries using a scorecard of 15
essential steps that should be taken during any delivery.
100% Active Management of
90%
Third Stage of Labor
Overall Delivery Score TAKEAWAYS
average scores (%)
80%
Clinical scores improve to 90%
70%
Postpartum
60% Quality is sustained over time
50% Unlike traditional training, scores are
Teamwork & Communication
sustained 6 months after mentors end their
40%
rotation in a facility
30%
Baseline Month 1 Month 2 Month 3 Month 4 Month 5Nurse Mentorship program: scaling status and impact to date
SCALE 54 facilities have been mentored and 550+ providers directly trained by mentors
IMPACT
newborn resuscitation
80% skills score
Mentored facilities consistently
90% perform 90% of essential
clinical steps during a delivery
Partograph* completions
90% increased from 42% to 90%
*A key WHO-recommended labor &
delivery documentation tool
Cheaper and more effective than the
current system of off-site trainingsSample Outcome Results: Nurse Mentor facilities show a decline
in cases of postpartum hemorrhage (PPH)
We
The extracted the last 12data
nurse performance months of data
we track from Kenya’s
(previous slides)Health Informatics
are strongly System
correlated (DHIS2)
in the and cases
literature with of PPH, before
improved and after
maternal and
introduction of the Mentorship program
newborn outcomes. To support this, we recently extracted the last 12 months of data from Kenya’s Health Informatics System
(DHIS2) on cases of PPH, before and after introduction of the Mentorship program. Here’s an example of early outcome data:
% Percent Change in rate of PPH, before/after Average PPH cases/month
Mentorship Program
County Average Mentorship Facilities
0.00
-5.00
-10.00
-15.00
-20.00
-25.00Path to integration: What is the value proposition to counties?
Cost of sending PROMPTS to Cost of mentoring a nurse
one mother over 6 months
$0.74Sustainability II: A step-wise approach to ensure long-term
government ownership of these programs
2018 2019 2020 2021 2022
Kiambu, Nairobi, Bungoma Add 4th and 5th county County 6,7 (Nakuru, Counties
County (Makueni, Kakamega) Machakos) 8,9,10
Adoption as
SUSTAINABILITY standard of care
Counties begin contributing to County Ownership in public health
MILESTONES operating costs of programs of programs
1 system
2
County partners are already
re-allocating staff and training
budgets to nurse mentorship
program. Counties cover costs of sustaining programs
(1) Allocating existing county staff resource and
budget lines for SMS and mentorship, and/or
(2) Link to govt pay for performance (NHIF) or
development financing sources (Global
Financing Facility)Counties are absorbing the cost of the nurse mentorship program
Counties have begun to allocate training budgets towards mentorship. By Q4 2020, we expect that other entities will bear over 65% of the program cost
of the nurse mentorship program based on current trends.
120%
Jacaranda Other entities
100%
8%
27%
80% 37%
45%
60%
100%
92%
40%
73%*
63%
55%
20%
0%
2018 Q3 Q4 2019 Q1 Q2 Q3
*We added two new counties in Q2 2019 and anticipate cost-sharing to increase in the next government financial yearProgress towards Vision 2021: County health systems are requesting
and deploying these solutions
2018 2019 2020-21
Partnerships and MOUs with 3 In discussions to roll out On track toward our goal of 10 key
county executives. Set up office in another 2 county counties covering 40% of Kenya’s mothers
Western Kenya to test expansion. partnerships and demand and babies in 2021.
from others.
Counties are already allocating their own budgets to cover the cost of these programs.Scale targets and projections for Kenya expansion 2019-2022
2019 2020 2021 2022
Number of Counties in Kenya
5 7 10 10
Total Number of Facilities Reached (mentor
facilities) 48 75 120 155
Total Number of MNH Providers mentored
(completing required curriculum) 384 600 960 1,240
Total number of deliveries impacted in
facilities 70,546 135,073 222,897 288,967
Total number of mothers and babies (2x # of
deliveries) 141,092 270,145 445,794 577,934
Cumulative # of mothers and babies, lives
improved 141,092 411,237 715,939 1,023,728Key Health Outputs and Outcomes in Target Facilities: 2022 Goals
Challenge Programmatic Targets Impact
Mothers do not seek care • 70% of women complete 4 ANC visits
at the right time and • 80% of women act on pregnancy and newborn
place during pregnancy danger signs 20% reduction in
severe postpartum
hemorrhage
Frontline providers have • Providers conduct essential clinical steps in 90% of
the obstetric and observed deliveries
• 90% of providers pass newborn resuscitation skill test
20% reduction in
newborn care skills to
• 95% of women initiate breastfeeding within 1 hour of neonatal mortality
save the lives of mothers
and babies delivery
Mothers seek care at the • 60% of mothers take up postpartum family planning
right time and place after at 8 weeks
pregnancy • 60% of mothers exclusively breastfeeding at 6
monthsJacaranda’s team and board
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